As a trained psychological autopsy investigator, Kelly attempts to establish what is unique about the suicide and the mental state of the victim. In addition to being a valuable tool for research on completed suicides, it also provides closure for people close to the deceased.
"You are going to places that can be very uncomfortable," Kelly said. "It is your job to reconstruct the mental state of someone who died by suicide, so in a way, you have to feel that. There is a role of empathic involvement where you put yourself in that position."
Her job is unique nationally. She was certified in 2013 by the American Association of Suicidology, and is the lone psychological autopsy investigator in South Dakota.
Locally, she's better known as professor of behavioral sciences and psychology at Dakota Wesleyan University.
Since becoming certified, she has investigated three cases in Mitchell and more than a dozen cases nationally.
Following a suicide, sometimes months later, Kelly's investigative process includes interviewing the next-closest of kin. Kelly explained initial interviews can last anywhere between two to eight hours.
"It gives people the opportunity to talk about the person in a fuller context," Kelly said. "We talk at length about who this person was before they died. They are beautiful stories."
In addition to family members of the decedent, Kelly interviews others who knew the person, such as teachers, friends or co-workers. After Kelly conducts all the interviews and reviews a person's medical and criminal files, she puts together her final findings into a three-page report.
"What we are doing is reconstructing a story because everyone has a side to a story," Kelly said. "We are trying to get an accurate picture based on the information provided."
There are three main questions Kelly tries to address: Why suicide? Why this method? And does this suicide make sense?
According to the American Association of Suicidology, in 2015 over 40,000 deaths by suicide were reported. In South Dakota, 173 deaths by suicide were reported, making the state rank seventh nationally per capita for suicides.
Kelly said that while there is research available on individuals who attempt suicide, information on why a person completes a suicide is not as well researched. Information provided from each case helps determine certain risk factors for individuals who died by suicide.

"If we really want to know what is going to bring somebody to complete a suicide, we need to study that group," Kelly said.
Kelly explained the typical timeframe to start work on a case is two to three months after the death by suicide. Each case is completed within three to four weeks, but it is dependant on how quickly Kelly can have access to the medical records. Kelly receives cases from contract work through a national agency or individuals who request services.
"Often when someone dies by suicide that person is now defined by their death," Kelly said. "This helps contextualize the death for the loved ones on why did this happen."

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Josh's Psychological Autopsy Report narrated by Ann Kelly.

Listen or Read Report

Josh was born in 1977, on Saturday, September 3rd, to parents, Tom and Donella, and was, also, welcomed by his older brother, Ryan. Typical (in the best way), Josh’s childhood and
adolescence would not predict his suicide at the age of 38. Josh was raised in a stable, two-parent
family where both parents worked. He grew up in a good neighborhood, which contributes to positive long-run outcomes. Josh attended neighborhood schools. Born after the age cut-off date
to attend first grade, he started school at seven-years-old and repeated a grade, making him nine in the second grade. As a result, he was bigger and more mature than the other children. This can contribute to hardships in childhood and adolescence, but Josh, who was sociable and physically active, made friends easily. He spent his childhood and adolescence biking, sledding,
and playing pick-up hockey. Josh loved hunting and fishing. He played trumpet. He listened to music and played video games.
Josh had a deep emotional bond with Donella. He had a good relationship with his maternal grandparents. Close grandparent-grandchild relationships are often a marker of strong family ties
overall and contribute to a child’s well-being. Sometimes, Josh’s relationship with Tom was marked by arguments, communication problems, and anger. It is easy for feelings to get hurt when there are conflicts like these. Arguments can lead to humiliation and resentment and contribute to more trouble. But clashes like these are very common between children and parents. Having disagreements is normal, and quarrelling with your child does not necessarily mean you have a bad relationship.
Amidst the common turbulence of adolescence, one troubling event stands out: a close friend of Josh’s shot himself while hunting. This incident, understandably, shook Josh and may have had a long-term impact. Exposure to a friend’s suicide is a risk factor for future suicidal behavior; teens of friends who die by suicide are five times more likely to have suicidal thoughts that last two years or more.
Josh struggled in a regular school setting and finished high school at an alternative school that was flexible enough to meet his needs. This school was a good fit. Upon finishing, he attended technical school for a time. He started work as a concrete worker and loved working seasonally at a Montana ski resort. Josh suffered a back injury at work and underwent surgery in 2005 and 2012. Continued concrete work became impossible; Josh retrained as an electrician, although chronic back pain still made working very difficult.
Josh had minor incidents with law enforcement, including a few DUI’s and a disorderly conduct charge. After the second DUI, Josh received counseling.
He very much wanted to be married and had a strong desire for intimate and lasting companionship. One of his first long-term relationships was headed toward marriage. After an initial bout of cold feet, Josh attempted to revive this relationship only to discover that, in the interim, the woman had met and become engaged to another man. Josh took this very hard and it was around this time he started spending time alone and drinking more. This may have marked
the onset of his depressive symptoms. A subsequent, serious girlfriend was well-educated, friendly, and financially secure, yet her personal insecurities and need for constant reassurance
became burdensome and led to a breakup. Later, Josh hoped to pursue a relationship with a woman he met on an employee vacation but lost contact with her. Josh’s last girlfriend shared his
interests in fishing and boating. The ending of this relationship came at a time when Josh was still, and increasingly, struggling with major depressive disorder, anxiety, insomnia, bipolar disorder, and panic disorder, as well as auditory hallucinations contributing to paranoia and
isolation.
Parents bereaved by suicide struggle more with the issue of responsibility and who was to blame (or not to blame) for the death. They grapple with finding a rational answer to the question
“why?” that would make it possible for them to go on with their lives. But there is no single cause for suicide: suicide most often occurs when stressors and health issues converge to create
an experience of hopelessness and despair. A fuller and more accurate picture, however, albeit one drawn with fewer sharp contours, is one which, instead, considers the medical or
psychological risk factors for suicide.
Factors that increase the risk for suicide are separated into three categories: historical, environmental, and health and mental health.
Historical factors, which include childhood abuse, neglect, or trauma, family history of suicide, and previous suicide attempts, are lacking in Josh’s case. He was not the victim of family
dysfunction, childhood trauma, abuse, or neglect. The only historical risk factor for Josh, if any, may have been a suspected (although unconfirmed) previous suicide attempt.
Each of the risk factors classified as environmental were present for Josh and are addressed elsewhere in this report: access to lethal means, in this case firearms; relationship problems;
unemployment; stressful life events, which may include a death or job loss; and exposure to another person’s suicide.
The third category of risk factors includes those pertaining to health and mental health, and Josh had many of the latter to a high degree. Among these are depression, substance use problems,
bipolar disorder, anxiety disorders, schizophrenia, personality traits of aggression, and conduct disorder (these last three not present in Josh’s case). Josh’s physical health risk factors included chronic pain and insomnia. At the time of his death, Josh suffered from chronic back pain and was struggling with alcoholism, depression, anxiety disorders, insomnia, and bipolar disorder with atypical features, as well as auditory hallucinations and increasing isolation. Most of these,
as well as job loss and relationship loss, are powerful predictors of suicide called independent
risk factors.
Josh was living in chronic pain from degenerative disc disease, disc herniation, and nerve root compression. He suffered a back injury at work and underwent surgery in 2005. He consulted with physicians about pain management in 2007, 2011, and 2012. Excruciating pain landed him in the emergency room in 2012. Josh underwent a second back surgery. Although he reported some improvement, it was still very difficult to work.
Chronic pain predicts suicide risk. Approximately one-hundred million American adults live with chronic pain, many of them with pain so bad that it wrecks their work, their families, their
mental health, and their lives. There are no hard data on how many people with chronic pain die by suicide every year, but the suicide rate among people with chronic pain is known to be roughly twice that for people without chronic pain, suggesting that as many as 20,000 Americans a year with chronic pain will kill themselves. Back pain,specifically, is an independent risk factor for suicide. People with chronic back pain are more likely to attempt suicide, whether or not they also suffer from depression or another psychiatric illness. According to Dr. Mark Ilgen,
a clinical psychologist whose work focuses on improving treatment outcomes for patients struggling with chronic pain, “There might be aspects of pain that in and of themselves increase
a person’s risk. The pain itself is poorly understood and may be poorly managed. There’s not a clear treatment plan for chronic back pain. Patients may be frustrated with their care and more
hopeless and more at risk for suicide.” The situation is unlikely to improve until the federal government takes the pain epidemic seriously.
Josh had both a family history and a personal history of alcoholism. Tom was an alcoholic who completed a rehabilitation program in the late 70s and relapsed for a few years before stopping for good. Josh’s own struggles with alcohol were documented in medical records. In 2011, he reported to a healthcare provider that he had been sober for two months. He tried quitting again in 2012. Medical records from 2015 indicate that he was drinking at that time.
Alcoholism is a leading risk factor for suicide. The suicide rate among men with alcohol abuse problems is three times higher than among those without a problem. Alcohol is involved in over
a quarter of all suicides in the United States. More than one-third of suicide victims use alcohol just prior to death. Alcohol makes people more prone to attempting suicide by violent means like
using a firearm. Josh was intoxicated at the time of death. Postmortem analysis of vitreous humor showed an excessive level of acute alcohol consumption. Examination of suicide victims
has shown that those with levels of excessive acute alcohol consumption are 77 times likelier to use a firearm than those with no alcohol consumption. A specific link between suicide and
firearms is clear.
Josh loved guns and owned several. He liked oiling, greasing, and cleaning them. He was comfortable using guns and was an avid hunter. Because access to firearms is a risk factor for
suicide, professionals should, ideally, assess clients’ access and, if necessary, work with them
and their support systems to limit access. Lethal means counseling, however, is not required by
law and is often hindered by a politically-charged atmosphere. Firearms are part of the culture of the state, so mitigating the risks which come with gun ownership is difficult and can only be done effectively by creatively building on connectedness, responsibility, and safety-consciousness.
Yet another risk factor present for Josh was major depressive disorder. Josh consulted with a physician about depressive symptoms in 2011. At that time, he had been taking Lexapro for a
few years but sought a less expensive medication. In 2012, his symptoms were getting worse, and he consulted his healthcare provider. Shortly after, he signed himself into Prairie St. John’s
for treatment of major depressive disorder, alcoholism, and generalized anxiety disorder and checked himself out the next day. His depressive symptoms worsened. He visited his physician
whom Josh told he wanted to try Lexapro again. At a subsequent appointment, Josh reported that it was very difficult to work, take care of things at home, and get along with other people. In
2013, he did report that his depression was getting better, but by 2014 it had returned. Josh was still being treated for depression at the time of his death the next year.
Responsibly, Josh sought treatment for depression. Unfortunately, the medications he was prescribed (Lexapro, Cymbalta, Prozac, and Celexa) made him feel sick. Excepting brief periods
of relief in 2013 and 2015, his depression worsened.
Approximately 17 million adult Americans suffer from depression during any one-year period.
Depression is the most common condition associated with suicide. Those with depression are at 25-times greater risk for suicide than the general population. Depression is present in at least
50% of all suicides. Fifteen percent of patients with treated depression eventually die by suicide.
On top of chronic back pain, alcoholism, and major depressive disorder, Josh had insomnia, itself another known risk factor for suicide. In 2011, he consulted with a healthcare provider about difficulty sleeping, which he attributed to anxiety and racing thoughts. He was given Ambien
and, over the years, other medications as well, including trazodone, which is both a sedative and antidepressant. Nevertheless, Josh continued to report difficulty falling asleep and staying asleep and indicated only getting about four hours of sleep a night.
Insomnia can lead to a very specific type of hopelessness, and hopelessness by itself is a powerful predictor of suicide. The more severe a person’s insomnia is, the more likely they are to
attempt suicide. Studies have found that people with insomnia are up to twice as likely to die by suicide as people who do not have difficulties sleeping. Insomnia could be a cause or an effect of depression. It would appear that, for Josh, it was initially an effect of depression and anxiety, both of which it would later exacerbate.
Josh was also diagnosed with generalized anxiety disorder and panic disorder, again, both predictors of suicide. Generalized anxiety disorder involves excessive worry that interferes with
daily activities. It may be accompanied by physical symptoms, such as restlessness, fatigue, difficulty concentrating, muscle tension, or problems sleeping. Panic disorder is one of frantic hopelessness and an uncontrollable and overwhelming profusion of negative thoughts. The core

symptom of panic disorder is recurrent panic attacks. A panic attack is an overwhelming combination of physical and psychological distress. Because symptoms are so severe, many people who experience a panic attack believe they are having a heart attack or are suffering from a life-threatening illness. Panic attacks may occur with other mental disorders, such as
depression. Panic disorder, particularly fear of dying during a panic attack, is an independent risk factor for suicide attempts among individuals with depressive disorders.
Josh had shown some symptoms of bipolar disorder, but it was not until quite late that Josh was diagnosed with bipolar disorder with atypical features. People suffering from bipolar disorder are more likely to attempt suicide than those suffering from regular depression. Typical bipolar disorder is characterized by periods of depression alternating with periods of excessive energy.
During the manic phase, it is possible for a person to exhibit psychosis and delusions, symptoms which may account for the auditory hallucinations Josh was experiencing, although other factors
such as insomnia or psychosis may have been the cause. With atypical bipolar disorder, the oscillating moods are skewed, such that some people stay primarily depressed. Sometimes this
diagnosis is made to account for a patient’s poor response to antidepressant medication.
The many risk factors already described above were compounded by the breakup of Josh and his girlfriend. Relationship problems stand out among the different risk factors for suicide, both
generally and for Josh particularly. Terminating a relationship can boost suicide risk as well and is a strong risk factor for depression. Being in a committed relationship helps protect against stress and depression. People look to their romantic partners for security, comfort, and close
physical contact. All other emotional bonds become less important. As a result, this kind of relationship bond becomes an essential part of their sense of identity. When the relationship
ends, it means losing the sense of identity and security that a relationship provides.
At the time of his death, Josh, who had always been physically active and sociable, was withdrawing from activities and isolating himself in response to insurmountable struggles with physical and mental illness now made worse by auditory hallucinations and paranoia. It was more difficult than ever before for Josh to work and get along with others. With the collapse of
another romantic relationship, his prospects for long-term commitment and happiness seemed bleak. In the weeks preceding his death, his strength had been compromised by sickness. The
constant bickering which led to a breakup with his girlfriend flared up afterward into long fights.
On the night Josh died, circumstances and alcohol overwhelmed him, and he shot himself.
Tom, you wrote that Josh had a sad life. In the years leading up to his death, Josh indeed suffered from chronic back pain and struggled with alcoholism and multiple mental disorders. Although
Josh’s suffering would ultimately become unbearable and could not be outweighed, for many years Josh did seek help and took medication, and this despite both the stigma associated with
mental illness and the bootstraps individualism of the Great Plains.
Josh had a mother, father, brother, and grandparents who loved him. He made friends easily. He remained physically active and enjoyed being in the out of doors. Josh had girlfriends. He knew
what it was to be in love and to be loved. He worked hard, even when it was hard to work. And, sure, there were arguments and sometimes fights, but there are arguments and fights for all of us, and nobody dies. Up until the end, Josh searched for happiness and sometimes still found it. He spent his last summer fishing and boating, two things he loved to do. Josh’s life ended in profound sadness, but we must not let this sadness define for us what was, in fact, a much fuller life.